While the rate of heart attacks seems to have declined, absolute numbers have increased and this has been attributed to a greying population. Well-worn advice, given repeatedly by the Health Promotion Board and the Singapore Heart Foundation, includes stopping smoking, cutting salt and fat intake, and exercising regularly. With advances in the treatment of hypertension, high cholesterol, diabetes, 64-slice CT scan, angioplasty, stenting, bypass surgery and so on, many survive a heart attack but with some residual damage and possible heart failure.

In medical treatment, the focus has been on treating the symptoms of the disease. This philosophy has resulted in higher medical costs and insurance and health care but with minimal returns. 'A 2 per cent improvement is encouraging, but it is still very small,' said National Heart Centre's head of cardiology, Dr Terrance Chua. It seems we have not understood the underlying disease process and cause, even though there is extensive and compelling evidence in the more than 50,000 published scientific papers. The solution may lie in not masking the symptoms and ignoring the causes and providing the body with the means to function properly.

The well-worn advice given above is good but inadequate. Air pollution is present in the environment and not just from smoking. Free radicals are produced by myriad causes, for example, stress, poor diet, pollution, radiation from the sun, infection, ageing and even excessive exercise. Free radicals have been implicated in more than 200 diseases and ailments, not just heart disease. With damage to the blood vessel walls, cholesterol is deposited and accumulates over the years before causing complete blockage of the vessels, for example, the coronary blood vessels, resulting in a heart attack.

Even if one cuts out fats completely (essential fats will still be needed), the liver produces cholesterol from the fat deposits in the body as cholesterol is an essential item for hormones and so on. We know of thin people who have hypertension and heart attacks.

As for hypertension, treatment, which is given the rest of one's life, is intended to prevent the complications of the disease, but there is no treatment for the actual cause of hypertension, unless there is a surgical cause.

What amount of exercise is advocated? General terms like 'moderate' exercise are repeated like a mantra. It implies that in exercise, there are no specific measurements to determine how useful it is. We know of prominent people who were reported to have died from a heart attack while jogging, on the golf course or after a 'run' only to collapse at the front gate. We know of Olympic athletes who overtrain only to fall ill just before the final heat and have to withdraw from the competition. Scientific papers have shown that in exercise, glutathione (a small protein) levels decrease and improve after a period of time from hours to days depending on the fitness of the athlete. We also know that glutathione increases with exercise, but we do not know to what degree and with any consistency how it is done.

In published scientific papers, results showed a remarkable prevention of atherosclerosis in animal studies. In the experiment, two groups of pigs were fed rich fatty meals, but one group had immunocal as well. The animals were killed and their arteries examined. In the group without immunocal, their blood vessels were almost completely blocked by fatty deposits. In the other group, fed immunocal, their blood vessels were completely free and patent with minimal deposits of cholesterol and fat. Now that is impressive indeed.

If the blood vessels are protected and atherosclerosis can be prevented, surely it will mean every organ in the body will be better supplied with blood and therefore function better.

Scientists have known for a long time the effects of deficiency of glutathione but were unable to raise it effectively and safely, until now. Glutathione (GSH) is a small tripeptide protein which can be produced only in the cells of the body. The limiting factor in the production of glutathione is the amount of correct-bonded cysteine in the diet, whereas glycine and glutamate are plentiful. The correct-bonded cysteine is not abundant in our food. Even taking cysteine orally does not help to increase glutathione levels. After more than 18 years of research, Dr Gustavo Bounous of McGill University in Canada discovered immunocal. This GSH enhancer, with high levels of bonded cysteine, overcame the limiting factor and raise glutathione levels safely and effectively

Immunocal has been clinically proven to enhance GSH production in the cells of the body, to improve the immune system and much more, even in cases of hypertension, heart disease, atherosclerosis and so on.

For details, readers may refer to www.jwr.com.sg or call 6334 7707 or for scientific research papers, (link to pubmed search added by me).

Keep an open mind, examine the evidence and reach your own conclusion. I did and so can you.

Dr Walter Roland Chen

There are many studies involving whey protein supplementation, and angry doc thinks it holds a lot of promise for a number of conditions. But while it doesn't hurt to take curds and whey, it may be some time before we can conclude that whey is the cure of all our illnesses.

Do keep an open mind as Dr Chen suggested though, and have a look at the pubmed search I linked to above.

Also, do visit the website mentioned by Dr Chen in his letter - I think you will find it contains a lot more information than have been provided in the letter.

angry doc gets a feeling we will be revisiting this topic in the near future.

Thursday, September 28, 2006

Teen has sex and abortion after reading magazine

Well, it *might* happen. According to this letter anyway...Goodie bag has magazine with questionable contentsMY HUSBAND participated in the recent Safra Sheares Bridge Run. Participants of all ages took part in the event and they were given a free goodie bag.

In it was a magazine with an article entitled 'What to do if she is pregnant?'

It discusses the different options for a man who makes a girl pregnant. One of the options listed is to abort the baby.

Is it the policy of Safra to encourage irresponsible sex and encourage abortion even though it leads to, as the article acknowledges, "severe repercussions for her, both physical (she may become infertile) and mental (she could end up with depression from the trauma and guilt and have nightmares for the rest of her life')?

There could also be an enhanced risk of breast cancer following an abortion.

It surely cannot be Safra's policy to champion irresponsible sex and abortion.

The organising committee should have vetted the goodie bag's contents to ensure that they were acceptable. Safra's lapse is disappointing. I trust it will take steps to prevent this from happening again.

What happens if a young teenager were to take up one of the options suggested by the article?

We should be promoting wholesome values and strong families.

Also, we need to be sensitive to each other as this is a multi-racial, multi-religious society.

All of us have our own opinions about sex outside marriage and on abortion.

I would like a response from the organising committee.

Dr Tan Siew Pinangry doc is once again, as he often is, confused.So 'all of us have our own opinions about sex outside marriage and on abortion', but none of us should be allowed to mention abortion as 'one of the options' in an article on unwanted pregnancy, even when we highlight in that same article the physical and mental repercussions that may come with abortion, Dr Tan?

angry doc doesn't like abortions and he tries to have nothing to do with it at all. He is disgusted by the way some people repeatedly 'use' abortion as the *only* form of 'family-planning' they practise - that's really stupid and irresponsible.But is omitting all mention of abortion (with the hope that eventually no one will choose it because no one will even know that such an option exists?) really a viable strategy?Or should we openly discuss it as an option, but an option that comes with potentially severe repercussions, and one that should not be chosen hastily?Maybe angry doc is truly confused, and Dr Tan isn't against the idea of abortion or the mention of abortion at all, but just the mention of abortion in a free magazine?Perhaps we should just not put magazines in goodie bags in the future then. That ought to reduce the incidence of unwanted pregnancies.

Wednesday, September 27, 2006

Dr Angry and Mr Smiles

Monday, September 25, 2006

How NOT to argue for Alternative Medicine 3

Remember this letter?It has brought two replies to the ST Forum today.The first one was rather business like. The second one... well, the second one provides material for our intellectual exercise today.The term osteopathy actually covers a range of beliefs and practices and the term 'Doctor of Osteopathic Medicine' can mean different things depending on which part of the world you are in. I will leave the readers to find out more about the subject.

What is interesting to angry doc is how Dr Tio's letter contains some of the arguments typically used to support alternative medicine. I reproduce the letter in full below.Try and see which ones of angry doc's advice on how NOT to argue for Alternative Medicine would apply to this letter; angry doc has highlighted certain interesting key words and phrases to help you along.Answers on the back of a postcard or the comments section please. Chiropractors mislead patients? People respond differently to treatmentKindly allow me, as one of the longest-serving members of the osteopathy and chiropractic profession in Singapore, to comment on the letter 'Beware chiropractors who mislead patients' (ST, Sept 16).

Osteopathy and chiropractic share similar origins, philosophies and treatment techniques. We believe that "structure governs function" - the structure of the body's muscular-skeletal system affects body functions and health.

Through manipulation and other techniques, we restore balance to the body's structure and this allows the body to heal itself.

Typically, we treat people with aches and pains. However, we also treat patients suffering from other ailments such as digestive or respiratory disorders.

We treat the person, not the illness. And because every person is different, it is impossible for us to predict exactly how many treatment sessions a person needs - just as it is impossible to predict that a person with the flu will recover in two days or two weeks.

In general, acute problems, such as a locked joint, can be easily corrected with one or two treatments. Chronic problems, such as arthritic knee pain, or scoliosis (spinal curvature) require regular treatment over a period of time.

Each treatment session produces changes in the body which vary with the individual. We would access [sic] the condition of the patient during each consultation and customise the treatment accordingly.

Package deals, whereby every patient buys the same number of treatments, ignore the fact that every individual responds differently to treatment and has different needs.In our training, we are also taught that over-treatment - including treatment that is too vigorous and treatment given too frequently - can be as bad as, or worse than, no treatment. It can lead to a worsening of pain. Thus, we refrain from over-treating.

As a service to the public, some of us offer free screenings for scoliosis and other conditions. A number of scientific studies have shown that osteopathic and chiropractic treatment, especially when given in the early stages of a condition, can help patients avoid surgery, which can be painful, costly and risky.

Generally, we do this within our clinics as a form of service, not in public malls as a form of marketing.

I have witnessed the profession grow and develop over the past 22 years. When I set up my practice in 1984, there was only one chiropractic clinic in Singapore, and mine was the first osteopathic clinic.

Today, there are about 30 chiropractors and osteopaths practising here. Competition has greatly intensified and this has led some practitioners to market their services aggressively.

Yet the number of practitioners in Singapore is still minuscule. If you flip through the Yellow Pages of cities in the United States, Britain and Australia, you will find pages and pages of osteopaths and chiropractors.

I thank Ms Michelle Tan for highlighting a recent, but nevertheless unhealthy, development within the profession.

Being personally acquainted with the older and more established practitioners in Singapore, I can assure readers that they uphold high standards of integrity and professionalism.

Saturday, September 23, 2006

Quackbuster busted

It seems that Dr Wes has dubbed angry doc 'Singapore's Quackbuster'.angry doc thinks himself undeserving of that title. Here's why...Bonus Real-life Story (see Disclaimer)Yesterday I saw a teenaged girl with the complaint of chronic joint pain. I noticed she was wearing a bracelet that looked exactly like the Q-Ray bracelet pictured in this previous post, down to the flattened knobs at the ends.I just had to ask.angry doc: Why are you wearing that bracelet?girl: Er... my mom bought it for me.angry doc: Did she say what it's supposed to do?girl: Er... it's supposed to improve my circulation or something.I could have told her that her pain was not due to an impaired circulation and that it was probably a waste of money and time to wear the bracelet.But I didn't.angry doc did not doubt that the bracelet did not confer benefits above that of a placebo.angry doc did not doubt that the placebo effect in this case is ineffective (or else the patient would not have been here to see him).But most importantly, angry doc did not doubt that in this case, wearing the bracelet was a daughter's way of acknowledging her mother's concern.So you see, angry doc doesn't always practise what he blogs.Besides, the bracelet looked good on her.

Friday, September 22, 2006

Madness 2

Seems like angry doc is not the only disturbed by the letter discussed in yesterday's post.Here's a good reply to Mr Pereira's letter, with links to several relevant sites on the subject of mental illness.

Thursday, September 21, 2006

Madness

Madness.Where to begin?Perhaps from this news article then.(excerpt)CONVICTED wife-killer Mohamad Zam Abdul Rashid has been sentenced to life in prison.

The penalty meted out to Mohamad Zam, who did not show any emotions during sentencing but will be appealing, came nearly two months after he was found guilty of battering his wife Ramona Johari, to death.

He escaped the gallows after he was found to be suffering from frontal lobe syndrome, a personality disorder that is said to cause emotional liability with associated irritability and outbursts of anger.

But Mohamad Zam apparently didn't know about his mental condition and the need to be on medication for life.

angry doc didn't really pay any attention to the news then. A 'mad' guy kills his wife, he is put away in some place for the rest of his life where he cannot kill another person again. Case closed.But then along came this letter, which argued for a more compassionate approach towards people with mental illness.I reproduce passages from the letter:"I am disturbed by the harsh sentence meted out to 44-year-old Mohammad Zam Abdul Rashid, whom psychiatrist Stephen Phang testified had a mental illness that was not detected until his arrest.

Rather than put him behind bars, couldn't the court make it compulsory for Mohammad Zam to seek treatment at the Institute of Mental Health (IMH), where, with medication, counselling, love and the much-needed support of a good team of nursing staff, he can recover and go on to lead a normal life?""Reports of the mentally ill being put in jail add to the stigmatisation of mental illness because people will believe that all mental patients are violent and troublemakers.

When you lock a person up, the damage can be extensive. During the Sars period when the Ministry of Health closed the door to all hospital visits, my wife, who was confined in IMH for a month, became very fearful. She took almost a year to recover from a relapse of schizophrenia.""Clearly, there is a lack of understanding of mental illness in Singapore. The structural support for caregivers is also very weak and that is why many of them give up and abandon loved ones who are stricken with mental illness.

In its review, the National Mental Health Committee should look at laws to protect the mentally ill, structural support for caregivers and public- education programmes that will help to better manage mental illness."Frontal lobe syndrome is not schizophrenia, but nevertheless the author made some valid points. Perhaps only a very small percentage of metally-ill persons are violent, but while it may be too extreme to not take the presence of mental illness into account in sentencing, it is perhaps irresponsible to the rest of society to be too lenient when the person in question has actually killed someone.But others do not share his view, as apparent from three letter to the ST Forum today.This one in particular was... interesting.Compassion for mentally ill offenders? Law must run its courseI refer to the letter 'Treat mentally ill offenders, not jail them' (ST, Sept 16) by Raymond Anthony Fernando.

I must disagree with his call for compassion for offenders who have mental disease. A crime is a crime, and a person has to pay for his offence, whether he is mentally stable or unstable.

A mentally unstable person can prove he is schizophrenic or mad (if he prefers the term) and then claim insanity as his defence in our law courts. But his lawyers have to prove that he was actually legally or medically insane at the time of the crime. It's as simple as that.

To allow mentally unsound people to go around killing, murdering, raping normal citizens and then plead for compassion for their crimes is very unfair to normal people like me. It will encourage anarchy and lawlessness in our society.

It is the duty of the family of the mentally unsound to ensure that they receive adequate treatment and hence remain in a stable condition, with proper medication, which needs daily supervision.

But we have to ask a simple question: What is mental instability? What is insanity? Is a hot-tempered person who suffers from so-called bipolar disorder mad or mentally unsound? Can he or she claim "insanity" as a defence too? It seems ambiguous to me.

In a recent Oprah Winfrey episode, Linda Hamilton, the famous Hollywood actress, stunned the audience by admitting that she suffered from bipolar disorder. However, she still managed to work throughout her life and in fact acted exceedingly well in The Incredible Hulk. She did not consider herself "mentally unsound" in any way. It was to her an inherent genetic condition which she accepted as part of her character. She did not consider herself "insane" or mentally incompetent.

The great poet T.S. Eliot also suffered from bipolar disorder, characterised by mood swings. But he never considered himself "mentally unsound". He in fact won the Nobel Prize for Literature.I think Singapore society still has difficulty accepting schizophrenics or those suffering from other mental diseases. But the truth is: Nobody is born mad. Anybody can get depression, and if not controlled, this can lead to manic depression, and if not controlled, could lead to schizophrenia or some other forms of mental instability.

It is the duty of the patient to take care of himself and not commit crimes and use mental disease as an excuse. And it is the duty of his or her family to help the patient to keep his disease in check.

But we all have to pay the price for our crimes, be it murder, rape, assault or any acts of violence.

The negligence of the family of the mentally unsound normally results in these acts. Stress triggers off a final onslaught and an "act of momentary madness" which results in a crime. It's up to the courts to then decide what is the best punishment.

For me, it's very simple. If a person can prove his madness at the time of committing his crime, he is legally insane and should not be executed or hanged by virtue of "insanity" but he should be confined to an asylum thereafter and receive adequate medical care for life.

If he cannot prove his offence was caused by mental disease, he should hang. If not, we can all go out and murder one another and then claim "insanity" as a defence, even if we are totally sane and had reacted more in a fit of passion or anger. Is this fair? I think not.

Basil Pereiraangry doc was brought up with the understanding that mentally-ill patients who have killed are locked up in a special ward in the mental hospital. They don't get executed, but neither can they cause harm to others again; so in a way he doesn't disagree with the author's argument that:"If a person can prove his madness at the time of committing his crime, he is legally insane and should not be executed or hanged by virtue of "insanity" but he should be confined to an asylum thereafter and receive adequate medical care for life.If he cannot prove his offence was caused by mental disease, he should hang."

But angry doc is disturbed by the way the author argued for his case.Frontal lobe syndrome is not bipolar disorder or schizophrenia.'Nobody is born mad', but there are strong genetic and prenatal factors involved in the development of schizophrenia. And while there is a correlation between depression, manic-depression, and schizophrenia, it is inaccurate to say that one leads to another. More importantly, nobody *wants* to become mad.One of the characteristics of being 'of unsound mind' is being unable to take care of oneself. To say that it is 'the duty of the patient to take care of himself and not commit crimes and use mental disease as an excuse' is like saying it's an immunocompromised-patient's fault that he can't fight off infections.But what is most disturbing to angry doc is the sentiment revealed in the following paragraphs:"To allow mentally unsound people to go around killing, murdering, raping normal citizens and then plead for compassion for their crimes is very unfair to normal people like me. It will encourage anarchy and lawlessness in our society.""If he cannot prove his offence was caused by mental disease, he should hang. If not, we can all go out and murder one another and then claim "insanity" as a defence, even if we are totally sane and had reacted more in a fit of passion or anger. Is this fair? I think not."

It sounds as if the author feels that 'killing, murdering, raping' are activities that are unfairly denied to 'normal people', who undoubtedly would go forth and commit these crimes aplenty if they knew all they faced in punishment was a lifetime of imprisonment instead of death by hanging. What a frightening world Mr Pereira lives in.

Quackbuster: Singapore

It seems like the Health Sciences Authority comes closest to playing this role here.

From their Annual Report 2004 - 2005:"As part of our ongoing post-market surveillance programme, we rely on various sources of information, including information obtained from field and media surveillance, to detect defective health products and health fraud. We received a total of 542 complaints in the year. 62 product defect reports were received and 94 products assessed. We conducted 31 product recalls for western medicinal products and CPM [Chinese Proprietary Medicine] due to concerns over their safety and quality requirements, such as contents of active ingredients not within specification limits, toxic heavy metals above permissible limits and the presence of adulterants.Legal actions were taken against errant and non-compliant dealers. During the year we completed 37 prosecution cases in court, resulting in $302,000 worth of fines being imposed by the courts and five cases with imprisonment terms. In addition we also issued 37 composition notices amounting to a total of $30,800 in fines for the year."

Monday, September 18, 2006

How NOT to argue for Alternative Medicine 2

Dr Han, in his comment in one of my previous posts, brought my attention to this BBC news article.Well, the BBC has previously been acccused of 'misleading viewers in an attempt to exaggerate the power of alternative medicine', so let's look at the studies mentioned in the news article ourselves.angry doc knows nothing about cost-effectiveness analysis, so he shall look only at the trial.Also, angry doc doesn't have the BMJ, so he can only rely on the abstract to form his initial opinion. (He will try to get his hands on a copy of the article though.)angry doc notes, for a start, that the study involved 289 patients with 'persistent non-specific low back pain' of whom 241 were randomised (why were the other 48 excluded from the study?).Of the 241 included in the study, 160 were assigned to the acupuncture arm, and 81 to the 'usual care' arm. angry doc wonders why the split wasn't an even fifty-fifty.Of these subjects, only 213 remained in the study at 12 months, and only 182 remained at 24 months. In other words, 11% of the subjects dropped out of the study after the first year, and 24% of the subjects have dropped out of the study after two years.Did these 11% and 24% come predominantly from the acupuncture arm, or the 'usual care' arm?Why *did* they drop out?What does angry doc make of the study?Well, for a start we have 289 people with 'persistent' back pain. This means that they are likely to have undergone 'usual care' to begin with and are unlikely to benefit from a further round of 'usual care'.The study utilised the SF-36 pain scale, which is a subjective scoring system. Fair enough for a study studying pain and for double-blind trials, but given that the study involved patients who had gone through 'usual care', one would expect those in the 'usual care' arm to report a higher pain score. They were probably reporting a high pain score under 'usual care' to begin with, so why should they suddenly change their tune when they *know* they are being given more of the same? Wouldn't you feel like an idiot if you told them you felt better with the same treatment?

Of the initial 289 patients referred for the study, 17% were not included in the study. Of the 241 who were enrolled in the study, one out of four did not complete the study. In fact, of the 289 patients referred for the study, only 63% completed it. More than one in three did not complete the study.

angry doc suspects that the percentage of drop-out from the 'usual care' arm is higher than that from the acupuncture arm. After all, if you have been under 'usual care' for a long time, would you be happy to stay in a study where you have 'more of the same' for another two years? Given the choice, angry doc would prefer the acupuncture arm himself. Perhaps that accounts for the uneven split into the two arms?

The authors themselves concluded that '[w]eak evidence was found of an effect of acupuncture on persistent non-specific low back pain at 12 months, but stronger evidence of a small benefit at 24 months'.

Note also that the patients' '[f]unctional disability was not improved', so while they were said they were *feeling* better, they weren't *doing* better.

Given that the study seems to be loaded in favour of acupuncture, angry doc remains unimpressed with the results.

1. The subjects were a heterogenous group, with complaints of back pain ranging from 4 to 48 weeks. 4% of those referred actually got better even before being enrolled into the trial.

2. The study did not study acupuncture per se, but a 'package of care' which included 'individualising of treatment', 'practitioner's skills at developing good therapeutic relationships', and 'process benefits such as protected time and attention from the practitioner'.

One may argue that acupuncture in practice comes in a 'package of care', but that begs the question of whether acupuncture is a vital part of the care, and if so by what degree.

Can one, for example, have an individualised acupuncture treatment with a practitioner who is not skilled at developing good therapeutic relationship, and have good outcome?

Or with 'usual care' with a practitioner skilled at developing good therapeutic relationships, with the process benefits of protected time and attention from the practitioner?

Having read the paper, angry doc gets the feeling that the study was not a scientific inquiry into the efficacy of acupuncture as a mode of treatment, but an attempt to use the scientific method to argue for cost-effectiveness of acupuncture as a treatment, with the object that it will result in more funding from the NHS.

angry doc would once again like to thank Dr Han for bringing the study to his attention.

Confidence Goods 3

angry doc has seen several of his patients wearing bracelets that look like the one below:

He wasn't aware (until he read this entry from Dr Wes' blog) that they are called Q-Ray bracelets, or that they are touted to have pain-relieving properties.Or at least they were, until a US federal district court ruled that the claim was false and that the manufacturer had to refund its more than 100,000 buyers.

The judge cited this Mayo Clinic study in his ruling, which showed that subjects who wore the bracelet *did* report significant pain relief, but no more than subjects who wore placebo bracelets. Interestingly, the percentage of subjects who experienced pain relief was similar to the percentage of subjects who believed (before the trial started) that the bracelet worked.The attorney acting for the manufacturer argued that the "mechanism is not an issue" as long as users experienced relief from the bracelets.

I suppose whether it is an issue depends on whether you are looking at it from the point of view of those who did experience relief, or those who forked out between US$60 to US$250 for a bracelet but experienced no relief.They do look nice though, don't you think?Anyone knows where angry doc can get one of those (presumably cheaper) placebo bracelets?

Saturday, September 16, 2006

How NOT to argue for Alternative Medicine

I wrote this one up yesterday but Blogger ate it up.But I thought the fine letter provided by the writer (mentioned in this previous post) utilised so many same-old-tired flawed arguments for Alternative Medicine, it was too good to pass up.So here's angry doc's advice on how NOT to argue for Alternative Medicine.

"All very constructive, this evidence-based name-calling, but there are some serious issues at stake here.

The first is the implied infallibility of the mainstream health professions, namely that their methods are always right, and ours are always wrong. Clearly, neither is true. Anecdotally, we all know of cases where GPs failed to notice something serious and doled out take-two-aspirin-and-go-to-bed-early advice when the realities were far more serious.

As an osteopath, I have come across cysts and tumours missed by patients' GPs and I have had patients come to me exasperated by the failures of mainstream treatment. That is not to say doctors are bad at their job, I do not wish to characterise GPs in the same way some GPs characterise us (earlier this year, osteopaths were accused of "sham treatment"), since that is clearly not the case. After all, many patients are sent to me by more enlightened members of the profession, but there ought to be a wider recognition of the diagnostic basis of much complementary treatment."

1. Two wrongs do not make a right

Just because western medicine is not infallible does not make alternative medicine effective. Argue with logic and evidence, not smear tactics.

"Osteopaths and chiropractors (the areas I am most familiar with) train for four or five years, learning anatomy to the same degree as doctors, as well as studying physiology, the respiratory system, the cardiovascular system, pharmacology and pathology, among others, which all help in our diagnostic triage - we are becoming more and more often the first port of call for many patients.

All patients undergo a detailed documented case history when they first see an osteopath, where we screen for any medical conditions and assess their suitability for osteopathic treatment. The insinuation that the professions are peopled with fly-by-nights with no real medical knowledge is untrue, insulting - and unworthy of the wider medical profession.”

2. Garbage in, garbage out

It is the quality of the subject you study that makes the difference, not how long you spent studying it. Just because you spent years studying it doesn’t make the subject of your study 'right'. Don't go on about how much you study - prove the results of your study with evidence.

3. It's not a popularity contest

Just because more people are coming to you does not mean you are right either – it just means you are popular.

"Again and again, doctors refer to evidence bases as their catch-all for ruling out complementary medicine. In practice this is fine - though it comes from the profession that brought you thalidomide and is beginning to wonder whether rushing herceptin through the net was really so wise."

4. Don’t knock evidence - you might need it later

Evidence-based medicine does not rule out alternative medicine - alternative medicine rules itself out of mainstream medicine by its own unwillingness or inability to provide quality evidence.

If you reject 'evidence' as the basis for deciding whether a mode of therapy should be accepted or not, what do you propose to use to back your own claims?

1. Two wrongs do not make a right (yes, using the same flawed argument a second time in the same letter still doesn't make it right)Yes, thalidomide is bad for you. Vioxx may be bad for you too. But lots of other western medicine drugs are good for you. Again, two wrongs do not make a right, so pointing out the failures of western medicine does not support the position of alternative medicine.

"However, the medical profession is a multi-million pound industry backed by pharmacological giants. The complementary sector cannot compete - we cannot pay for trials, we do not have multi-nationals encouraging treatment dependency."

5. Be honest – it *is* about the money

The alternative medicine business is *also* a multi-million pound industry. More than a billion pounds, it seems.In fact, if like you said more and more people are using alternative medicine, that makes it a multi-million pound *growing* industry.

You can't claim to have no money for trials because unlike the Big Pharmas, your therapies are traditional and natural, and do not take millions of pounds to develop!

"It is the exact opposite - if there is a theory underlying all complementary medicine, it is that the human body works quite well on its own and needs tweaking as little and as naturally as possible. If you want clinical evidence - how about millions of years of human history?"

6. 'Natural' doesn't mean 'better'

It is not natural to have chlorine-disinfected drinking water or smallpox vaccination, but those things do a lot of good.

Hemlock, on the other hand is all natural, as is dying of malaria.

Having your spine manipulated on a chiropractic couch, having steel needles stuck into you, and having a burning candle stuck inside you ear are not natural, so don't knock your own practices.

"Ironically, one of the few areas that a large-scale trial has been done is the area that started this current row. Homeopathic medicine is indeed controversial, as in order for a homeopath to treat a patient, the person's individual symptoms have to be taken into account in order to make an individualised prescription. This means that homeopathy does not perform exceptionally well in random controlled trials - where one group of people are all given the same medicine and another group are given a placebo."

7. Don't use 'individualised' as an excuse for a lack of system

If every individual is special, then how does a homeopath know what treatment to prescribe for each of them?

Either there is a system where signs and symptoms allow a patient to be diagnosed of a condition or a syndrome, and a treatment be recommended, or there is no system.

If there is a system, it can be studied.

And if there is no system, why bother spending years studying it? In fact, how do you teach or learn it?

(Yes, angry doc scoffs at the idea of 'individualising treatment' in western medicine too; it’s just putting people into smaller pigeon-holes – they are still not 'individuals'.)

"When homeopathic trials are based upon individualised prescriptions we see a very different picture. At the end of 2005, the results of a large six-year study of 6,500 patients at Bristol Homeopathic Hospital reported 75% improvement in their health."

8. Learn statistics, and learn how to design a proper trial

A few thousand people saying that they *feel* better about their health does not make a trial – it makes a survey.

Also, surveying follow-up patients imparts a bias to the survey and make it a poor study.It’s a bit like surveying repeat customers at a restaurant – if they didn’t like the food there they wouldn't be back in the first place.

"The sad thing about arguments such as this is that both sides of the medical divide could work at their best together.

Earlier this year, a report commissioned by Prince Charles (OK, bear with me - he didn't write it) said that patients using the "big five" complementary therapies - osteopathy, chiropractic, acupuncture, homeopathy and herbal medicine - would greatly benefit from their treatment, while the NHS would reap economic rewards.”

9. Don’t appeal to authorityEspecially when the authority is not an authority on the subject.

"The report was written by Christopher Smallwood, who commented at the time: "The weight of evidence we have examined suggests that complementary and alternative medicines could play a larger role in the delivery of healthcare, and help to fill recognised gaps in healthcare provision."He went on to call for the NHS's drugs watchdog to assess the cost-effectiveness of complementary therapies and he asked the government to boost funding for the therapies on the NHS."

The contents of this publication constitute research, the results of which have not undergone clinical trials or any other form of testing or validation for the purposes of any kind of medical treatment, diagnosis, therapy or advice. The said contents are published for the purposes of information only. None of the said contents should be considered medical advice or a recommendation of medical treatment or therapy. This publication should not be relied upon as a basis for administering or seeking medical treatment, diagnosis or therapy and neither commissioners, financiers or related parties, nor any of their employees, subcontractors or agents shall be held responsible for any action that you take in reliance upon any of the information contained in this publication. You should always consult your health care professional for specific advice relating to any medical questions.

"Such support is welcome, even if the basis is economics not health, and the new rules on homeopathic treatment are a small step in the direction of bringing complementary medicines into the mainstream - a journey already made by physiotherapists, after all. But while snide asides about eye of newt and wing of bat continue to emerge from those in the medical profession who forget why we use the word complementary in preference to alternative (it is alongside, not instead of), it will be a struggle. And the real losers will be the patients."

11. Try to gain acceptance on your own merit

It doesn’t matter whether we call you 'alternative' or 'complementary' – if you can’t provide evidence for efficacy, you should not be accepted.

Physiotherapy proved its efficacy, and nobody calls physiotherapy 'alternative' or 'complementary' – they call it 'physiotherapy'.Trying to gain acceptance by quoting the example of physiotherapy just makes it look like you think you can't make it on your own merit.Well, there they are.angry doc would have liked to keep the list of advice to a nice round number of ten, but blogging is not an exact science...

Confidence Good 2

A letter to provide angry doc some weekend musing...Beware chiropractors who mislead patientsIN MAY I came across a chiropractic road show in the basement of a shopping centre promoting 'free' back and neck computerised spinal assessment. There were two chiropractors on hand to explain the findings of the computer assessment and one of them diagnosed that I had a condition that needed to be treated.

I confirmed that I had been in a car accident and was in constant pain and undergoing physiotherapy. I also informed this person that my two infants had been in the accident as well and I was offered a discounted detailed assessment if I paid up that day. This would take place in their clinic over the course of two days. I paid for all three of us to be assessed.

After the first assessment, I received a telephone call informing me that the chiropractor was moving his clinic. At the second session in the new clinic, I was told I would need a total of 44 treatments over 18 weeks, at the rate of three a week. I was strongly encouraged to purchase a 'package' at $2,450 which would bring down the cost of each treatment from $70 to $54.

The chiropractor also examined my sons, aged 3½ and 1½, and told me that there were problems with them. In addition, one of my older boy's legs was shorter than the other. If not treated, these would cause serious problems.

After my third session, when I felt worse instead of better, I decided to stop the treatment as I was suspicious and alarmed at the constant 'reminders' by phone and SMS to keep my appointments. Sometimes I would receive two calls and an SMS reminder in a single day for an appointment that evening that was made two days earlier. A few weeks later, I received a call saying the chiropractor was moving again.

My children have since been examined by their paediatrician and another chiropractor who both confirmed they are fine.

I am concerned that these unscrupulous practitioners could be exaggerating conditions in an attempt to sell treatment packages and preying on the concern and sometimes paranoia of parents.

Michelle Tan (Ms)

Unlike the two other posts this week, this one is not about alternative medicine.Really.Afterall, Ms Tan did not decide from her adventure that chiropractry was quackery. In fact, she consulted another chiropractor for a second (third?) opinion.So why did Ms Tan decide that the original chiropractors were 'exaggerating conditions in an attempt to sell treatment packages and preying on the concern and sometimes paranoia of parents'?That they has a road show? Well, various 'medical' societies hold road shows and free health screenings too.That they were selling their service in a package? Well, obstertrics departments sell antenatal packages too.That they sent reminders for appointments? Well, hospital specialist outpatient clinics send reminders for appointments too, and as I recall this was well-received by some patients.That she felt worse instead of better after her treatment? Well, maybe; but then again no other medical discipline can guarantee that a patient will feel better after the third session of a projected 44-session treatment. In any case, her physiotherapy must not have been too effective, or she would not have been in 'constant pain' and felt the need to give chiropractry a try.That a paediatrician and another chiropractor both 'confirmed' that her children were fine? Interesting. What makes the 'confirmation' from the two more trustworthy than that from the original chiropractor? Was it a case of 'two against one'? If so, what if two chiropractors 'confirmed' that her children were fine, but one paediatrician said otherwise? Or one paediatrician versus one paediatrician and one chiropractor?The constant clinic-moving was dodgy though, I'll admit.I suspect it was a combination of all the above factors, and perhaps some others which Ms Tan chose not to express in her letter.angry doc remains relatively clueless about how patients decide if their healthcare providers are quacks.He would also like to know what the original chiropractor thought was the cause of Ms Tan's son's limb-length discrepancy was, and how he proposed to treat it though.

angry doc is disturbed by the fact that the MHRA titled its press release "Improved patient information and greater consumer choice", when most patients (or are they consumers? angry doc is confused) are probably unaware that different labeling standards apply for 'western' medicine and alternative medicine remedies.

Like it or not, government 'regulation' is often seen as approval or even promotion. Calling patients consumers does not change the fact that they are sick people who may be misled into thinking that they are taking a proven cure for their illness when all that regulation means is that the product has not been shown to be harmful.

Disclosing this to reporters during his trip to China, Minister of State for Trade and Industry Lee Yi Shyan said this may be explored further in the free-trade agreement being discussed between China and Singapore. Currently, physicians and acupuncturists need to register with the TCM Practitioners Board, a regulatory body set up in 2001, before they can practise in Singapore.

Meanwhile, Singapore's largest public health care group, SingHealth, is in talks with Chinese authorities to set up a high-end private hospital in Shanghai, targeted at the expatriate community there. — Channel NewsAsia

angry doc notes two things:1. The announcement was made by the Minister of State for Trade and Industry, and not someone from the Health Ministry.2. If TCM is so good that we want to 'import' more of it to Singapore, what makes them think that 'exported' western medicine will be in demand over at the home of TCM?

Saturday, September 09, 2006

"Broadcast News"

It's no secret that angry doc is no fan of the media, and so it came as a bit of a surprise to he himself that many scenes from the movie "Broadcast News" have actually been etched in his memory.Like the scene when William Hurt clasped his hands over his heart when he saw Holly Hunter's character at the ball.Or the line"It must be nice to always believe you know better, to always think you are the smartest person in the room."which he said to Blinkymummy the first time they met.And the way Holly Hunter's character would, upon reaching the office each morning, unplug her phone, and then proceed to weep at her desk.I think doctors don't set aside enough time to cry.God knows we've got many things to cry over.God knows we've got many people to cry for.

***

A couple of postings ago I saw a young woman referred to the clinic for a common symptom. Unfortunately examination revealed that she had advanced cancer.I remember I literally ran around the hospital to get her care co-ordinated quickly. She was warded under the care of the oncology department, which my senior T worked in. I popped over to see her a couple of times. Her condition was stabilised, and she was discharged. I hoped for the best.A few months later I saw her sitting all by herself at the hospital cafeteria, having her lunch. In between bites she stared into the distant. I watched her for a while before I walked over and said hello. She was there for her treatment. All by herself.I spoke with T later, and learnt that while the case was a little complicated, they were making some progress.So I was very surprised when I found out recently that she had died. Died from cancer.I was upset for quite a while.Not because she was young.Not because the cancer was unexpected.But because I remember the way she looked when she stared into the distance while she ate.I didn't cry though. I don't remember her having cried over her own illness either.

***

On an unrelated note, here's another quote from the movie, this time from Albert Brooks' character, which I've actually forgotten until I googled the movie up while writing this entry:"What do you think the Devil is going to look like if he's around? Nobody is going to be taken in if he has a long, red, pointy tail. No. I'm semi-serious here. He will look attractive and he will be nice and helpful and he will get a job where he influences a great God-fearing nation and he will never do an evil thing... he will just bit by little bit lower standards where they are important. Just coax along flash over substance... Just a tiny bit. And he will talk about all of us really being salesmen. And he'll get all the great women."Have a good weekend.

Wednesday, September 06, 2006

Yet another angry doctor...

Monday, September 04, 2006

Healthcare Group proposes Grading Scheme for Clinics

Bonus Bogus StoryThe Healthcare Group (HCG) led by Minister of State Ms Hor Ker Futt has proposed a Grading Scheme for General Practitioner (GP) Clinics in Singapore."We were inspired by the success the National Environmental Agency had with improving the standard of hygiene and housekeeping at food stalls with their grading system. We believe a similar system will encourage GPs to achieve a higher standard of care and service, and allow consumers to make a more informed choice when patronising GPs," said Ms Hor."With the IT system now in place to monitor the Key Performance Indicators (KPIs) of all the clinics, it is now possible for us to publish this data on the Ministry's website. However, it is felt that the average consumer may find it inconvenient to have to access the web to find this information, and that they may have difficulty interpreting the data. Hence, we propose that this information be presented in a simple, easy-to-understand grading scheme, and make each clinic display this information prominently on the premises."Under the proposed scheme, clinics in the top 10 percentile will be graded 'A', while those above the 75th percentile and the 50th percentile will be graded 'B' and 'C' respectively. Clinics below the 50th percentile will be given a 'D' grading."We understand that there may be concerns from GPs regarding this system. However, we will continue to monitor the KPIs and update the grades every quarter."The HCG also had another inspiration from food stalls."We are also proposing that a system similar to the 'Healthier Choice' implemented by the Health Promotion Board for hawker stalls be adopted by clinics. Clinics which give their patrons the option to purchase cheaper generic medications will display a 'Ask for cheaper drugs' sticker at their dispensary counters."Formed in August 2006, the HCG was given the task of studying how Singaporeans can continue to have access to good-quality healthcare at the out-patient, in-patient and step-down care stages, and be able to pay for it.

Saturday, September 02, 2006

Ownership

I didn't know there was such a thing as the yearly The Forum Editor Writes column, but here it is.Interestingly, the Forum Editor opens his column with some information about angry doc's topic of interest - complaint letters to the newspaper:"READERS of the Forum may have noticed that for certain medical issues, a reply from the hospital in question is published next to the letter of complaint.

The first such letter was from Ms Lee Limin, 'Possible cancer? All she had was eczema', accompanied by the reply from Changi General Hospital, 'Medical management was appropriate' (ST; Oct 6, 2005).

This is done where there is an allegation of serious misdiagnosis or a delay in emergency treatment. We do this because such life-and-death matters are emotive issues and it is important that readers get both sides of the story at the same time.

In all such cases, the writer's permission is sought before the letter is forwarded to the hospital for a response."Thank you, Mr Kong. This certainly is a step forward.